Healthcare Provider Details

I. General information

NPI: 1972227999
Provider Name (Legal Business Name): ANDRE CONN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11701 WILSHIRE BLVD STE 14B
LOS ANGELES CA
90025-1547
US

IV. Provider business mailing address

1225 N EDGEMONT ST APT 22
LOS ANGELES CA
90029-1555
US

V. Phone/Fax

Practice location:
  • Phone: 323-936-7525
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number302883
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: